Provider Demographics
NPI:1134277908
Name:RODRIGUEZ, MARISSA (RD, LD, CDE)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 MONTOPOLIS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-6411
Mailing Address - Country:US
Mailing Address - Phone:512-978-9449
Mailing Address - Fax:512-901-9749
Practice Address - Street 1:2901 MONTOPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6411
Practice Address - Country:US
Practice Address - Phone:512-978-9449
Practice Address - Fax:512-901-9749
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07407133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1819690Medicaid